The Social Health Authority (SHA) invites qualified individuals to apply for the position of Claims Management Officer II (Dispatch Centre). This recruitment aims to strengthen the institution’s capacity to manage emergency medical dispatch and claims processing in alignment with national healthcare quality standards. SHA plays a critical role in ensuring that the delivery of emergency, chronic, and critical illness healthcare services meets the highest levels of efficiency, transparency, and accountability.
As part of its continued commitment to operational excellence, SHA seeks dynamic and competent professionals who are passionate about improving the quality of health services across the country. The role is designed to provide structured training, exposure, and professional growth in claims management and quality assurance within the healthcare system.
The position of Claims Management Officer II is offered under the SHA Grade 8 classification and falls under the Contract terms of service. This opportunity offers 22 available positions, providing a platform for professionals from medical, nursing, and clinical fields to contribute their expertise to the efficient management of emergency medical dispatch operations.
The position is ideal for individuals who possess both a clinical background and a strong interest in health system administration, particularly within the domain of claims management and medical audit processes.
Overview of the Position
The Claims Management Officer II (Dispatch Centre) serves as an entry and training grade officer responsible for ensuring that all emergency medical dispatch cases and subsequent claims adhere strictly to established medical protocols, service charters, and SHA benefit packages. This includes particular emphasis on those governed by the Emergency, Chronic, and Critical Illness Fund (ECCIF).
The role requires high levels of accuracy, integrity, and clinical understanding. It involves extensive engagement with operational systems, clinical data, and healthcare service providers. The officer operates within the National Ambulance Dispatch Centre, a fast-paced environment that demands both technical and analytical capability to ensure that claims are validated efficiently and fairly.
This position is key in maintaining the integrity of medical claims management processes, ensuring that quality standards are upheld, and that fraudulent or inaccurate claims are detected and mitigated early. The officer works under close supervision of a senior officer, gaining exposure to claims management operations, clinical audits, quality assurance procedures, and the use of electronic claims management systems.
Key Responsibilities
The Claims Management Officer II (Dispatch Centre) is expected to undertake a broad range of duties and responsibilities under the guidance of a senior officer. The responsibilities include both operational and analytical tasks, all designed to uphold the quality and efficiency of SHA’s claims management systems.
1. Monitoring and Review
The officer plays a critical role in monitoring and reviewing medical-related customer interactions and claims initiated through the dispatch process. This involves ensuring that all cases recorded through the National Ambulance Dispatch Centre conform to SHA’s medical and service delivery protocols.
The monitoring process ensures that patient cases handled through the emergency dispatch system are accurately documented, and that the services rendered align with approved benefit packages. Any inconsistencies or deviations identified during this process are reported for immediate corrective action.
2. Quality Surveillance
Undertaking quality assurance surveillance is a key component of the officer’s work. The officer must conduct systematic reviews of claims and dispatch records to detect errors, discrepancies, or potential fraud.
By maintaining active surveillance over dispatch claims, the officer supports the Authority’s efforts in maintaining operational transparency and minimizing financial risk exposure. This surveillance process strengthens public confidence in the Authority’s management of healthcare funds and reinforces accountability among service providers.
3. Clinical Audits
Another core responsibility of the officer is to conduct clinical and service quality audits in line with SHA standards and medical protocols. These audits assess the accuracy and completeness of clinical documentation associated with emergency medical dispatch cases.
Through the auditing process, the officer ensures adherence to clinical standards, validates the appropriateness of medical interventions, and verifies that service providers comply with the Authority’s service charters. The audits also serve as an important mechanism for identifying systemic weaknesses in claims management and recommending improvement measures.
4. Compliance Monitoring
The officer undertakes compliance monitoring and quality assurance activities related to the handling of emergency cases. Compliance monitoring involves reviewing the consistency of service provision, evaluating whether providers meet contractual obligations, and ensuring that all procedures adhere to the Authority’s established frameworks.
This role demands attention to detail, clinical judgment, and the ability to interpret policy and procedural documents to ensure that compliance measures are implemented effectively.
5. Claim Validation
The officer assists in reviewing, processing, and validating medical claims from healthcare providers and facilities. This process ensures that claims are genuine, properly documented, and in compliance with the applicable benefit package guidelines.
The validation stage involves cross-checking service details against medical records, dispatch logs, and treatment documentation. The officer ensures that claims are neither exaggerated nor fraudulent and that every submitted claim corresponds to legitimate medical interventions.
6. Appraisal of Medical Claims
Under supervision, the officer assists in appraising medical claims based on the applicable benefit package, such as the Emergency, Chronic, and Critical Illness Fund (ECCIF). The objective of this appraisal is to determine claim eligibility and prevent misuse or overutilization of healthcare funds.
The appraisal process ensures fairness and consistency in claim settlements while safeguarding the Authority against unwarranted financial exposure. This responsibility is pivotal in maintaining the sustainability of healthcare funding mechanisms.
7. Pre-Authorization Management
The officer supports the issuance of pre-authorizations for access to healthcare services based on established benefit packages. Pre-authorization ensures that only eligible cases are approved for treatment or service access, preventing unnecessary costs and ensuring compliance with procedural and clinical requirements.
This task requires the officer to analyze clinical data and patient information, applying professional judgment and established guidelines to determine the validity of service requests.
8. System Operation and E-Claims Management
In the modern claims management environment, the use of electronic systems is critical. The officer assists in the operationalization of the e-claims management system, which facilitates efficient, transparent, and timely claims processing.
This role includes data entry, verification, and management of digital records to ensure accurate and traceable documentation. The officer ensures that the system functions effectively to support claims validation, processing, and reporting functions.
9. Fraud Control
The officer assists in implementing systems and controls for detecting and identifying fraudulent activities within the claims management process. This includes analyzing claim trends, identifying red flags, and reporting any suspicious activities for investigation.
Fraud detection plays a significant role in safeguarding healthcare resources and ensuring that funds are directed toward legitimate service provision. The officer contributes to maintaining a culture of accountability and ethical conduct across the Authority’s operations.
10. Sensitization and Awareness
The officer participates in the sensitization of claimants regarding the consequences of submitting false or fraudulent claims. By educating claimants and healthcare providers, the Authority minimizes the occurrence of fraudulent submissions and encourages compliance with ethical standards.
Awareness activities also involve communicating updates on benefit packages and procedural requirements, thereby reducing misunderstanding and ensuring smoother claims submission processes.
11. Data Analysis
Data analysis is an essential part of claims management. The officer is responsible for collecting and analyzing data related to claims processing, service utilization, and quality assurance.
The insights derived from data analysis inform decision-making processes and help in optimizing operational efficiency. Data-driven approaches also enable the Authority to identify patterns, detect inefficiencies, and propose policy-level recommendations for improvement.
12. Report Generation
The officer supports the preparation of detailed reports on compliance trends, clinical audit outcomes, and claims performance. These reports provide valuable insights for decision-makers and form the basis for strategic interventions aimed at enhancing service quality and operational integrity.
Monthly medical quality reports, audit summaries, and surveillance findings are compiled with recommendations for corrective or preventive measures. The reporting process is integral to ensuring transparency, accountability, and continuous improvement in claims management systems.
Professional Expectations
The Claims Management Officer II is expected to demonstrate professionalism, confidentiality, and a commitment to high ethical standards. The officer must maintain impartiality in claims assessment and ensure that all decisions are made objectively based on verified clinical and administrative information.
The position requires strong communication skills, attention to detail, and the ability to work within structured teams. As an entry and training grade, the officer will receive guidance from senior colleagues while being progressively exposed to more complex assignments.
Team collaboration, adherence to protocol, and continuous learning are essential components of this role. The successful officer will play a direct part in upholding the Authority’s mission of ensuring that every healthcare claim processed reflects fairness, accuracy, and clinical integrity.
Summary
The Claims Management Officer II (Dispatch Centre) plays an essential role in supporting the Authority’s vision of a transparent, accountable, and quality-driven healthcare system. By combining medical knowledge with administrative rigor, the officer ensures that all emergency medical dispatch and claims activities meet established national standards and protect the integrity of healthcare financing.
This position offers a valuable opportunity for medical professionals seeking to transition into healthcare administration, policy implementation, and operational management. Through structured training and mentorship, officers in this role contribute meaningfully to the broader goal of strengthening Kenya’s healthcare systems through efficient claims management practices.
Applications for this position are open to qualified candidates who meet the prescribed criteria and are ready to contribute their expertise to the Social Health Authority’s mission.
